Cycle 1
Health 2025-07-31 · Fire 2025-07-31
4 health deficiencies
Top issue: Infection Control (2 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Grand Marais, MN
North Shore Health
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
515 - 5th Avenue West, Grand Marais, MN
(218) 387-3040
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
37
Certified beds
Average residents
28
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1987-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.71
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.36
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.27
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.34
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
2.07
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.80
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
1.21
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
2.19
CMS adjusted RN staffing hours
Adjusted total hours
5.59
CMS adjusted total nurse staffing hours
Case-mix index
1.06
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
487
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
69.04
Composite VBP score used to determine payment impact.
Payment multiplier
1.0219
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
5.97
Baseline 34.62% · Performance 39.29% · Measure score 5.97 · Achievement 5.97 · Improvement 0
Adjusted total nurse staffing
7.84
Baseline 5.01 hours · Performance 5.31 hours · Measure score 7.84 · Achievement 7.84 · Improvement 3.36
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 2 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 27.85% |
8.2%
19.7 pts better
|
Numerator 44 · Denominator 158 |
| Staff flu vaccination coverage | 67.01% |
42%
25 pts better
|
Numerator 130 · Denominator 194 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.3%
2.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.3% |
96.1%
0.2 pts better
|
95.5%
0.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.6% |
3.9%
1.7 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 7.4% · Q3 3.7% · Q4 3.8% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.4% |
4.3%
3.1 pts worse
|
11.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 0.0% · Q3 9.5% · Q4 13.0% · 4Q avg 7.4% |
| Percentage of long-stay residents who lose too much weight | 10.5% |
4.1%
6.4 pts worse
|
5.4%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 15.4% · Q3 14.8% · Q4 3.8% · 4Q avg 10.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.1% |
12.4%
4.7 pts worse
|
19.6%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 15.4% · Q3 18.5% · Q4 15.4% · 4Q avg 17.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.2% |
17.5%
5.3 pts better
|
16.7%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 8.7% · Q3 12.0% · Q4 8.0% · 4Q avg 12.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.6% |
22.5%
0.9 pts better
|
16.3%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.3% |
18.6%
8.7 pts worse
|
14.9%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 28.0% · Q3 26.9% · Q4 20.8% · 4Q avg 27.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.5% |
2.6%
3.9 pts worse
|
1.7%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 7.4% · Q3 0.0% · Q4 11.5% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.7% |
24.8%
1.1 pts better
|
19.8%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 25.7% · Q3 27.0% · Q4 20.4% · 4Q avg 23.7% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
5.4%
5.4 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-01 · Fire 2024-08-01
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-08-17 · Fire 2023-08-17
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-03
F · Potential for more than minimal harm
2025-07-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-01
F · Potential for more than minimal harm
2025-07-31
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-09-01
F · Potential for more than minimal harm
2025-07-31
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-09-01
D · Potential for more than minimal harm
2025-07-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-07-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-15
F · Potential for more than minimal harm
2024-08-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-08-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-09
F · Potential for more than minimal harm
2024-08-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-10
F · Potential for more than minimal harm
2023-08-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-15
F · Potential for more than minimal harm
2023-08-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-15
F · Potential for more than minimal harm
2023-08-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-08
F · Potential for more than minimal harm
2023-08-17
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-15
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-31
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-07-31
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-02
D · Potential for more than minimal harm
2025-07-31
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-09-19
C · Minimal harm
2025-07-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-03
D · Potential for more than minimal harm
2024-08-01
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-08-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-30
F · Potential for more than minimal harm
2023-08-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-13
Penalties and ownership
What sits behind the stars
Ownership
Cook County Hospital District
Operational/Managerial Control · Organization
Hansen, Catherine
Contracted Managing Employee · Individual
Wraalstad, Kimber
Operational/Managerial Control · Individual
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